Wellness POTD: What Do Our Attendings Do in the Winter in NYC?

Happy Friday everyone!

Winters in NYC can be cold and long, but I'm a firm believer there's magic in the city if we search for it a little (too sentimental, I know, but it's true). So for this wellness POTD, I crowdsourced some of our EM attendings for recommendations on how they spend their days this time of the year. 

The question was simple: do you have any traditions, activities, or sightseeing you like to do with your loved ones during the winter in NYC? The responses are humorous, heartfelt, ice skating-infused, and thoroughly delightful. Enjoy.

Dr. Reuben Strayer: "My christmas tradition is to eat birria. My favorite birria tacos at the moment are at El Mexicano Restaurante & Cafe Bar (https://maps.app.goo.gl/ELzrXxUDdYuW7LLG6)."

Dr. Eustace Lashley: "When the kids were younger and wanted to hang with us, we took them to the Christmas show to see the rockets at radio city music hall. Stroll on 5th Avenue and view the displays at Sachs, view the Xmas tree at Rockefeller center. My wife took them ice skating while i watched. The Macys window display was also a hit. Have dinner at a restaurant of my wife’s choice. Now I keep out the city at Christmas 😀😀."

Dr. Eric Roseman: "Ice skating! Bryant Park, Central Park or Prospect Park. And candy cane flavored chocolate bark." (I wanted to clarify if the bark was homemade, to which the response was "def buy, but that would be cute if I made my own.")

Dr. Emily Unks: "Bryant park holiday market is cute. And the nutcracker!! Also going to serendipity on upper east side, featured in my fav rom com ever and has ridiculous hot chocolates and ice cream. Or drinking and going to hawaii."

Dr. Julie Cueva: "Here are some kid friendly activities: ice skating at prospect park (and sledding if it ever actually snows!) Bronx Zoo Holiday Lights, sip hot chocolate and walk through Dyker Heights Lights. We’ve done the tree but they didn’t seem to care too much about it, mostly just wanted to check out the toy stores near by!"

Dr. Laura Gonzalez: "Honestly, my favorite holiday activity is to walk around the various neighborhoods.  NYC is the consummate walking city; you get a sense of the diversity and joy when you walk it and that goes for anytime of the year.  The holidays are even more fun because the decorations are often over the top 😊 Some are color coordinated with tasteful lighting and deliberate designs; others are just chaos - yards with giant blown up santas surrounded by smaller snowpeople, lighted menorahs, and even random left over Halloween paraphernalia.  Gotta love it💕. Also, walking is free, open to all, and good for your health and mind 😊."

Dr. Sneha Shah: "Sundays in Brooklyn in Williamsburg has the cutest holiday pop up called Snow Day in Brooklyn and they have really good cocktails with cute names and very cozy decor!!"

Dr. Lawrence Haines: "I go skiing with my kids. Spend time with family. Go to Miami every year in March."

Dr. Kimbia Arno: "Union Square Holiday Market!"

Dr. David Shang: "I'm depressed during the winter."

Dr. Evan Mahl: "While there are lots of touristy things to do in NYC (Rockefeller Center), for me the winter holidays in NYC are best filled with eating and drinking out with friends and family in clubby and warm restaurants. For steak lovers, I've been digging Hawskmoor Steakhouse on Park and 22nd. The main dining room is an historical beauty, but the best scene is at the bar. They serve what they call the world's coldest Martini and it's a winner. They serve excellent oysters and burgers at the bar, but the steaks are great too. Other NYC classic gems include Gramercy Tavern and Minetta Tavern. If you want to stay in Brooklyn, you can't go wrong with Gage and Tollner (definitely grab a drink at The Sunken Harbor Club, their upstairs tiki bar.)

Lastly, a fun and festive day is always to be had at Chelsea Market on 9th Avenue. It's filled with lots of fun restaurants and shops. It's a great place to sample some oysters and beer at The Lobster Place (their seafood restaurant Cull and Pistol is also great). For meat lovers head downstairs to Dickson's Farmstand Meats; Israeli street food is right at Mizon; Korean grub at Mok Bar; and some of the best tacos in NYC at Los Tacos # 1 (and their seafood taco joint, Los Marisocs). End the day with some sweets from Lilac Chocolate, then bundle up and walk along the Hi-Line.

Dr. Josh Schiller: "Lightscape in Brooklyn Botanic Garden (https://www.bbg.org/lightscape?gad_source=1&gbraid=0AAAAA9p0StKQx9K86zXjBR0IRPNU2mZCt). The lightshow is nice for kids."

Dr. Sabrina Sokolovsky: "I have to think about this because I don't like Christmas very much...My holiday is Halloween."

Dr. Carmen Cortis: "Christmas time is my favorite time of year especially in NYC. It is truly magical here. Since my birthday is on Dec 27, I try to recreate a family tradition my father started for me ever since I can remember. Every year we would go see the Christmas spectacular at Rockefeller center, go ice skating there underneath the beautiful Christmas tree, eat at the Plaza hotel for dinner and then take a ride through Central Park on horse and buggy. I would look forward to it every year and my mom and I still do it every year in his memory."

Dr. Mert Erogul: "We like to gather friends and family for Thanksgiving and make leg of lamb or duck instead of turkey. With the duck you can render the fat and use it year round for frying potatoes. Also everyone knows turkey is so very overrated."

Dr. Myung Bae: "I like Brooklyn Bridge Ice Skating that started last year. Christmas live jazz/bar at the Roxy Bar. Rolfs is a must visit during Christmas, Papillon Bistro is somewhere we go every holiday season, Miracle on 9th Street, and most importantly Petes Tavern."

Dr. Eric Quinn: "Probably Christmas shopping at Macy's herald square."

Dr. Smruti Desai: "My favorite winter tradition is getting the F out of nyc. But realistically hot pot. And snow fights in prospect park."

Dr. Duo Xu: "Traditions: ice skating at Bryant Park, Xmas tree at Rockefeller, Xmas lights at dyker heights, winter wonderland light show at Citi Field. And eat hotpot everywhere lol. I'm kinda excited to see the new bluey exhibit coming out in the winter too lol."

Dr. Danny Novak: "One of my favorite things to do during the holiday season with my family is visit Bryant park for the winter village. There is always great food, little boutique stores, and lots of activities to do for all ages. We also love to see the tree and ice skating at the Bryant park ring during our day out at the winter village! We usually end the day with having dinner at the Bryant Park Grill Restaurant."

Dr. Amy Sanghvi: "Bryant park market. Union square market. A tree I love in the Bloomberg building. Pete’s or paddy’s for the decor. Madison sq park tree lighting. Ice skating Bryant park. Almost always go away for a weekend upstate to try to see snow. The macys windows. I have kids so my list is quite PG."

Dr. Shivani Mody: "The holidays in NYC are my favorite time of year! I love taking my kids to soak up the magic of the season—wandering through the Winter Village at Bryant Park, seeing the Rockefeller Center Christmas tree, and catching the Saks light show. Yes, it’s all a bit cliché, but it never gets old! For date night, my husband and I have our own traditions—watching The Nutcracker at Lincoln Center and grabbing drinks at the Empire Hotel (any other Gossip Girl fans out there?)."

Dr. Kai Wang: "We have gone to the dyker heights Christmas lights and winter village/ice skating at Bryant Park."

Dr. Michael Lamberta: "Finding parking on the left side of the street before it snows… 🤔 checking out the Bryant Park winter market and making mulled wine."

Dr. Eric Lee: "I like ice skating in Bryant Park and strolling the holiday market afterwards. Hot beverage and mulled wine is closest that it feels to christmas markets in Europe. I also like walking down 5th Ave and catching the light show outside Saks. Take advantage of being an EM doc and do all this on a weekday. Don't go on the weekend or week of Christmas."

Dr. Irina Sanjeevan: "This might be lame but my fave thing in winter is finding tasty hot chocolate/teas/ramen/soups to eat haha so usually very food-based activities! Walking around the cold with a loved one and a delicious hot chocolate in hand is my fave."

Dr. Kay Odashima: "For me, it’s all about sharing warm, cozy foods with family and friends. A favorite at home is nabe (Japanese hot pot) or cheese fondue. If I’m going out, I’m game for any place that serves mulled wine. When it snows enough (which didn’t happen last year) we love to take the kids sledding on the little hills at Prospect Park."

Dr. Ryan Lebuhn: "https://freshnyc.com/blog/where-go-best-mulled-wine-or-spiced-wine-nyc"

Dr. Matt Friedman: "Go to Turks and Caicos!! Ok, I'll think of something more local. Frozen hot chocolate at serendipity on East 61st or 60th. Watch the thanksgiving day parade balloons get blown up on the night before the parade on the upper west side. Get Banana Pudding at Magnolias and wander through Central Park with long johns on in case it's cold. Go to 4 and 20 blackbirds for a thanksgiving pie. Matzah Ball soup at the world renowned Second Ave Deli (on 33rd and Third Ave) to offset the frosty weather."

Dr. Jon Rochlin: "When the kids were little, we went to radio city music hall to see the rockettes. We'd sometimes go skating at Rockefeller center. The holiday lights in dyker heights followed by pizza at L&B spumoni."

Dr. Dave Eng: "Snowy cabin weekend in the Hudson Valley with warm cider and board games while watching the snow fall."

Dr. Gary Maida: "At the first semi substantial snow fall in NYC a great Staten Island tradition is to go sledding with the family at Silver Lake Golf course. Hundreds of families fill the golf course sledding on various hills. We then go warm up on Forest Avenue with a famous cheeseburger at Duffy’s! Just call me if you get a summons for trespassing."

Dr. David Lobel: "Light show. When the kids were smaller there were holiday lights at The Bronx zoo, and train show at the NY botanical garden. These are close to Arthur avenue where a hearty Italian meal would follow. These days, the Brooklyn Garden has also started a holiday light show. Photo to follow."

Dr. Jessica Zerzan: "I like a fire. And I will recommend others sit by a fire and figure out how to dismantle the patriarchy."

Happy adventuring in the city,

Kelsey

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Upper GI Bleeds and Management!

Hello friends,

Today’s POTD will be on upper GI bleeds and what to do when they come. UGIB can seem really terrifying sometimes but hopefully next time you have a patient with an UGIB you remember these next few steps. 

Upper gastrointestinal (GI) bleeding is a potentially life-threatening emergency that requires rapid recognition and intervention. These are patients that tend to end up in our resus bay, can rapidly decompensate, require blood products  and airway protection. 

Step 1. Start with the ABCs! 

  • You want to make sure the airway is protected

    • Intubating these patients can be very messy and tricky, suction will be your best friend in this scenario! 

  • Access is very important especially if you expect having to transfuse these patients 

    • Two large-bore IVs are key! If access is an issue or patient is hemodynamically stable secondary to blood loss, you may need to insert a cordis  

Step 2. Once your ABCs are ensured, try to identify the source of bleeding

  • Is this a UGIB secondary to varices? Peptic ulcer disease? NSAIDs? Anticoagulation? Does this patient have liver disease and portal HTN? Hx of prior GI bleeds? 

    • If you are able to maintain a history or obtain collateral than it can give you some insight as to what is going on 

Step 3. What are we ordering for these patients?

  • Well obviously we are obtaining labs, make sure to get a CBC and a type & screen

  • What about medications?

    • Proton pump inhibitor: 80 mg pantoprazole IV

    • Concern about a variceal bleed? Add octreotide (this will reduce splanchnic blood flow)

    • Give IV antibiotics, specifically ceftriaxone, in these patients to prevent infections 

Step 4. Who are we calling for these patients?

  • GI consult! Sometimes these patients require an emergent or urgent endoscopy 

  • ICU! As stated before, these are very sick patients who may quickly decompensate, these patients may also be intubated 

Now, lets say you did all these steps but the patient has taken a turn for the worse and requires intubation while actively vomiting blood? Good news, there is the SALAD technique! 

The SALAD (Suction-Assisted Laryngoscopy and Airway Decontamination) technique is a critical approach for managing airways in patients with significant vomiting or massive upper GI bleeding, it allows you to clear the airway to optimize visualization.

How-to-perform the SALAD Technique: 

    1.    Setup is key: Get a rigid suction (e.g., Yankauer) and connect it to continuous suction. Position the patient appropriately to prevent aspiration (head elevated or reverse Trendelenburg).

    2.    Decontaminate the Airway: Before attempting laryngoscopy, aggressively suction the oropharynx to remove blood, vomitus, or other secretions. Continuously suction while inserting the laryngoscope and during visualization. You are basically inserting the suction into the esophagus so that way you have a better view for intubating. 

    3.    Insert the ET Tube: Once the airway is clear enough for visualization, proceed with intubation

Enjoy this 1 minute video on how the SALAD technique works: https://youtu.be/ZOwNSpDG6vY?si=FG1KMdrDOnXII7Xf 

Resources:

  • EMRAP

  • UpToDate

  • WikiEM

  • Core Pendium -Approach to GI Bleed chapter

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POTD: Call Back Requests in SCM

Hi everyone,

Today's POTD comes at the request of frazzled tele docs past, present, and future: how to properly request a follow-up call back in SCM. 

By virtue of being a busy urban ER in NYC, we might find ourselves sending patients home with results still pending. The choice to send home a patient with pending results is a discussion between you and your God/attending, but the process of submitting a case for a call back should follow a few general principles.

4 Golden Rules of Call Backs

1) Advise patients that they will receive a call back only if there is a positive finding for results or tests. Emphasize: no news is good news! If they don't receive a call back, it means their test was negative. If the patient is persistent and still wants a call back for negative findings, then make a note of it in the Call Back Reason box. 

2) Specify what it is that you want the call back for in the Call Back Reason box. If you click lab results, instead of writing "lab follow-up", specify the test or value you're focused on. If you click diagnostic test, instead of writing "xray results", include which xray and what you're concerned about. If you click follow-up call, include what clinical symptoms or disease progression you're monitoring. If we don't provide a bit of context, the tele doc has to go chart digging for no reason. See below for what this looks like at the bottom of the ED Disposition Note in SCM, and compare it to what the tele doc sees on their follow-up list.

3) Do not give a call back for urine culture or STI results. The process of call backs is that the next day's tele doc gets a list of call back requests from the last 24 hours. Urine culture and STI results will inevitably not be available within 24 hours of the patient being seen, so to include next-day call back requests for these results is meaningless. However, the results of urine culture and STI testing are sent out on a regular basis to future tele docs (see below), and any positive results will automatically get a call back when they result. The only exception is that if you have high concern for STI test results, you can include it as a call back so that the tele doc can keep an eye on it.

4) Verify phone numbers! You can find a patient's phone number printed on the Discharge 123 forms below the signatures on the Patient Signature Form. It is the very first sheet in the Discharge 123 packet, and then is repeated again after the instructions and results. When you're discharging a patient, be sure to confirm the number is correct. If the number is incorrect, or especially if there is no number at all, write in the call back box the correct number.

Follow these 4 simple rules for call back requests and every tele doc will sigh in relief.

Happy calling,

Kelsey

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